Medicare Patients Advanced Beneficiary Notice

The ABN (Advanced Beneficiary Notice) is a document provided to Medicare patients  by a provider prior to a service that is being given that is unlikely to be covered by Medicare.  The notice indicates that the service is not going to be covered and the patient agrees to personally pay for the charges for the service(s).  Usually, an ABN is used when medical necessity is not met, but the doctor and patient wish to proceed with the service anyway with the patient being fully aware of the charges and that they will be responsible for them.

As a medical biller, you will need to keep ABNs on hand and file them in the patient record. Without an ABN, the patient “could” have a legal leg to stand on to deny payment for the services. So, the ABN protects both the patient in allowing them to understand the charges and that they will  probably not be covered, and it protects the provider in that they fully disclosed this information to the payment before rendering the service(s).

Medicare Patients Advanced Beneficiary Notice

Cost estimates are not mandatory to have on an ABN because the main purpose of the notice is to simply make the patient  aware that Medicare won’t cover the service.  One interesting thing about ABNs is that you do NOT have patient’s sign them when Medicare NEVER covers a particular service. You only need to get them when the service is “sometimes” covered by Medicare but sometimes not. Again, this is usually determined by “medical necessity.”

Conversely, when a service is NEVER covered by Medicare, you would want to have the   patient sign a NEMB (Notice of Exclusion Of Medicare Benefits). This is a different form, which a medical biller should be familiar with and have on hand.  Of course, both forms would be filed in the patient record.

Failing to obtain signatures, dates, and the proper documents in a medical billing situation may create situations that appear to be abuse or even fraud. Additionally, the provider may not get paid for the service at all and would not have a strong case if they failed in their duties to notify the patient properly.  As a medical biller, you should seek to become educated on what Medicare does and does not cover.

By: Dawn Moreno, PhD, CPC, CBCS, CMAA, MTC. Lives in the beautiful Southwest United States and has been an instructor for medical coding/billing for the past 7 years.  Interested in quality medical billing training? 

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Healthcare Compliance for Medical Practice Managers

AAPC – Certified Proffesional Compliance Officer